Endoscopic Sleeve Gastroplasty: Current Status and Future Prospects: Insights by Dr. Prabu Doss

Obesity remains a global health crisis, affecting millions and contributing to a range of comorbidities such as diabetes, hypertension, and cardiovascular disease. Traditional approaches to weight loss, including lifestyle modifications and bariatric surgery, have limitations—either in efficacy or accessibility—prompting the development of minimally invasive alternatives. Among these, Endoscopic Sleeve Gastroplasty (ESG) has emerged as a promising option, offering a less invasive, effective, and potentially reversible method for managing obesity. Dr. Prabu Doss, a leading figure in bariatric endoscopy, has provided valuable insights into the current status and future prospects of ESG, shedding light on its transformative potential in obesity management.

Current Status of ESG

ESG is a relatively new endoscopic procedure that reduces gastric volume by creating a sleeve-like structure along the stomach's greater curvature using full-thickness sutures. Unlike surgical bariatric procedures like laparoscopic sleeve gastrectomy (LSG), ESG requires no incisions, reducing recovery time and operative risks. Since its introduction in 2013, ESG has gained traction worldwide due to its favorable safety profile and efficacy. Multicenter studies have demonstrated its ability to achieve significant weight loss—typically 15-20% of total body weight within 12-24 months—while maintaining a low rate of severe adverse events, generally below 5%.

Dr. Prabu Doss emphasizes that ESG fills a critical gap in obesity treatment. For patients ineligible for or hesitant about surgery due to its invasiveness or cost, ESG offers a viable alternative. Its repeatability and potential reversibility further distinguish it from surgical options, allowing adjustments based on patient needs. Current evidence highlights its success in not only promoting weight loss but also improving metabolic conditions such as type 2 diabetes and non-alcoholic fatty liver disease. Moreover, ESG's minimally invasive nature has led to its adoption in diverse settings, from academic medical centers to community practices, showcasing its reproducibility and scalability.

The procedure's mechanism involves altering gastric motility and delaying emptying, which enhances satiety and reduces caloric intake. Dr. Doss notes that while the precise physiological underpinnings of ESG-induced weight loss are still under investigation, the combination of mechanical restriction and hormonal changes likely plays a role. Studies have shown sustained weight loss up to five years post-procedure in some cohorts, suggesting durability that rivals surgical outcomes for certain patients. However, ESG is not without challenges. Weight regain remains a concern, particularly in older patients or those with poor adherence to lifestyle changes, underscoring the need for multidisciplinary support.

Future Prospects of ESG

Looking ahead, Dr. Prabu Doss envisions ESG evolving into a cornerstone of obesity management, driven by technological advancements and a deeper understanding of its long-term impacts. One key area of development is the refinement of endoscopic suturing techniques. Current methods, such as the “U” stitch pattern using devices like the Apollo OverStitch, are effective but could be optimized for greater consistency and efficiency. Innovations in suture materials or automated suturing systems may enhance procedural outcomes, reducing operative time and improving gastric remodeling precision.

Another promising prospect is the integration of ESG with pharmacotherapy. Dr. Doss highlights emerging research suggesting that combining ESG with anti-obesity medications, such as GLP-1 receptor agonists, could amplify weight loss, potentially matching or exceeding surgical benchmarks. This hybrid approach could cater to a broader patient population, including those with higher body mass indices (BMIs) who might otherwise require surgery. Additionally, personalized treatment plans leveraging machine learning to predict ESG success based on patient demographics, comorbidities, and lifestyle factors could optimize outcomes and resource allocation.

The expansion of ESG indications is also on the horizon. While currently targeted at patients with BMIs between 30 and 40, its application in overweight individuals (BMI 27-30) or as a bridge therapy for super-obese patients (BMI >50) is being explored. Dr. Doss advocates for large-scale randomized controlled trials to validate these uses, noting that robust data could elevate ESG’s status in clinical guidelines and increase insurance coverage, addressing a major barrier to accessibility. Furthermore, its role in managing weight regain after prior bariatric surgery presents an untapped opportunity, potentially reducing the need for revisional surgeries.

Challenges remain, however. The long-term efficacy of ESG beyond five years is not fully established, and questions linger about suture durability and the risk of complications like gastric perforation, though rare. Dr. Doss stresses the importance of addressing these gaps through longitudinal studies and standardized protocols to ensure consistent outcomes across centers. Additionally, cultural and ethnic differences in obesity pathophysiology—such as the higher visceral fat accumulation in Asian populations—may necessitate tailored approaches, a nuance that future research must consider.

Insights and Vision

Dr. Prabu Doss’s insights underscore ESG’s potential to revolutionize obesity care by offering a middle ground between conservative treatments and surgery. He views it as a patient-centered option that aligns with the growing demand for less invasive interventions. Its ability to improve quality of life and comorbidities early in the disease process could shift the paradigm toward earlier intervention, preventing the progression of obesity-related complications. However, he cautions against over-optimism, urging a critical examination of its limitations and a commitment to evidence-based practice.

In conclusion, Endoscopic Sleeve Gastroplasty stands at an exciting juncture. Its current status reflects a safe, effective, and adaptable procedure that has already transformed lives, while its future prospects promise even greater impact through innovation and broader application. Dr. Prabu Doss’s contributions highlight the need for continued research, collaboration, and adaptation to unlock ESG’s full potential. As the obesity epidemic persists, ESG could emerge as a vital tool in the global fight against this chronic disease, offering hope to millions seeking sustainable weight loss and improved health.